Committee Discusses Pneumococcal Vaccines, HPV Vaccine Schedules

In what AAFP alternate liaison to the ACIP Margot Savoy, M.D., M.P.H., described as a fairly uneventful meeting, the only official vote was to recommend live attenuated influenza vaccine (LAIV; FluMist) be administered to young children rather than inactivated influenza vaccine. Other topics covered included weighing which pneumococcal vaccine should be recommended for adults and which HPV vaccine should be recommended and on what schedule.

This young girl is receiving the live attenuated influenza vaccine.

LAIV Recommendation

At the meeting, the ACIP voted unanimously to recommend LAIV for healthy children ages 2-8 years. The influenza workgroup examined research that showed healthy young children were less likely to get the flu when given the nasal spray versus an injection.

"(Young children) tended to tolerate receiving the live vaccine because they had a good immune response, which was a better response than if they just got the shot," Savoy told AAFP News.

Savoy said the recommendation drew a handful of concerns from participants. One notable concern voiced during the discussion was that the recommendation would be released in June but practices had already ordered their flu vaccines back in January.

"Now there would be a rush of parents who all want the spray vaccine for their children, and a demand has been created that your practice might not be able to fulfill," she said.

The second concern was that a recommendation now would leave too short a timeframe for practices to revise their vaccine information system protocols to reflect the new recommendation and the patient population it targets.

Story Highlights

During the CDC's Advisory Committee on Immunization Practices (ACIP) June 25-25 meeting, the group voted to recommend live attenuated influenza vaccine for healthy children ages 2-8 years.

ACIP members discussed whether to recommend the pneumococcal conjugate vaccine versus the pneumococcal polysaccharide vaccine for adults, but no consensus was reached and voting was tabled until a future meeting.

More action is needed before the ACIP can make a recommendation on HPV vaccines, weighing the candidate nine-valent HPV vaccine against a revised schedule for the currently marketed quadrivalent HPV vaccine.

In response to concerns from some ACIP members that the IIV shot could be seen as an inferior choice, Savoy emphasized that is not the case. "If all you have in your office is the injectable, then you should use it. But if you have both, then offer the FluMist," she said.

"What the ACIP absolutely doesn't want you to do is delay giving children influenza vaccine. If you have a child in front of you in the office, but you know that your FluMist won't be in for two weeks, give the shot that you have in the office right now."

Pneumococcal Vaccine Debate

Discussion regarding whether the ACIP should recommend the pneumococcal conjugate vaccine (PCV13) versus the pneumococcal polysaccharide vaccine (PPSV) focused on the adult population, but no decision was made, and voting was tabled until a future meeting, Savoy said.

According to Savoy, the conversation started with the question: If you had to choose only one shot to give, which would you choose?

The PPSV vaccine covers more types of pneumococcal bacteria (23) but not as well as PCV13. "(The immunity the PPSV vaccine provides) wanes, so you would still be alive when the protection went away," she said. And that's a problem, because when you are older, you are at higher risk for getting pneumonia.

On the flip side, PCV13 offers longer-lasting protection, said Savoy, "But now instead of being protected against 23 types, you are only protected against 13." And two or three pneumococcal bacteria types that cause invasive disease and can lead to sepsis are not among the 13 types the vaccine covers.

In a perfect world, a physician would give both vaccines separated by a year to retain the initial vaccine's efficacy, said Savoy. The problem with that scenario, however, is that Medicare currently pays for only one dose of pneumococcal vaccine.

The pneumococcal workgroup has been charged with gathering more evidence to review during an August conference call/webinar meeting that will be scheduled and open to the public. The full committee is expected to take up the topic again at its October meeting.

HPV Discussion Continues

Savoy is a member of the ACIP workgroup on HPV, which led a discussion during the meeting about the candidate nine-valent HPV vaccine and the quadrivalent HPV vaccine (Gardasil).

The quadrivalent vaccine is currently indicated as a three-dose series in the United States. Although a number of other Western nations have adopted a two-dose schedule, which has been shown to improve adherence while still maintaining high levels of protection, the FDA has not yet approved the shortened schedule.

Instead, Merck Inc., which manufactures both Gardasil and the candidate nine-valent vaccine, is focusing on its nine-valent HPV vaccine, said Savoy. "So the ACIP had to decide, 'Do you make a recommendation on the nine-valent vaccine that will (likely) be available and FDA-approved this December? Or do you wait for the two-dose vaccine schedule for the quadrivalent drug to be FDA-approved and make a recommendation there instead?'" Savoy said.

The nine-valent vaccine is expected to be released and gain FDA approval sometime around the end of this year. The workgroup plans to review and present research on the candidate vaccine at the October ACIP meeting, and perhaps a vote on a recommendation can be taken at the committee's February meeting, said Savoy.